American College of Physicians: Internal Medicine — Doctors for Adults ®

Thursday, July 30, 2015

Becoming a clinician--observations from third year students

The transition between the basic science years and the clinical years in medical school are jarring, mystifying, exhilarating and thought-provoking. Yesterday, I did an hour conference with approximately 30 medical students. About half started their clinical year 5 weeks ago, while the remainder have only 3 weeks left before they finish the year. They gave me permission to share our discussion. We focused on their (and my) observations about the adjustments they were making. The following list is not complete, but rather what we talked about for an hour. We welcome your comments on additional observations.
1. Clinical students work independently, talking with patients, examining them, and developing their own assessments prior to presenting/discussing those findings with residents and attending physicians. The students found this both exhilarating and scary. Several endorsed the “imposter syndrome“. Patients see students as learning physicians, but they actually understand that students are on a trajectory and they are not imposters. This transition is a challenge for many students, interns, residents and newly minted attending physicians. We discussed and acknowledged the feeling. But we also observed that thousands of students have gone through the process and succeeded.
2. Students must learn to ask for help. Those physicians in position to help understand that the students need help. Not asking for help is a huge mistake, but brand new 3rd year students start out feeling intimidated. Successful students learn how to ask and receive excellent help.
3. One quickly learns that you cannot invent the stories that patients tell you. Many stories are incredible. The best physicians appear non-judgmental, although we all have judgments. To get the best story, we cannot appear to be judging patients. Students, interns, residents and physicians cannot really share their interesting or incredible stories with non-medical people. What we find interesting and worthy of discussion bores or disgusts our “regular” friends. I suspect that is one reason 3rd year medical students often appear boring to their non-medical significant others. Our story telling to our peers is therapeutic and necessary, but only in our own groups.
4. Once you start the clinical years you begin receiving calls, texts and e-mails from friends and relatives about their medical problems. This phenomenon never ends. The students were happy to hear that this is a common problem and that they needed strategies to answer such inquiries. Everyone else sees us as experts.
5. Third year students enjoy reading about the clinical problems that their patients have. Adult learning observations support this phenomenon. Reading about medicine during the first 2 years is a job; reading about your patients becomes an obsession and that obsession is necessary, enjoyable and rewarding.
6. Beware cynical health care workers. Beware having cynicism intrude into your personality. We discussed why cynicism develops. We discussed patients trying to manipulate us. One student shared a thought that I had given him. We should trust all patients, but we should always verify their difficult to believe stories. We also talked about the problems of pain and opiate seeking patients.
7. A great observation from a student – Doctors use Google – a lot! She realized that she had always had doctors on a pedestal assuming perfect knowledge. The third year exposure confirms that we physicians are human. We stressed that having physicians look up drug doses or information about a diagnosis while rounding is a very positive trait. We also all agreed that physicians do not live on a pedestal.
8. Medical students should act like medical students, understanding the systems expectations of their knowledge and behavior. They should not act like residents or attending physicians. They should work to become great medical students and prepare for the next step in their climb.
9. We discussed the difficult exposure to mortality. Some students shared their observations of watching a patient die. These episodes impact us dramatically. At first they are very difficult; they never become easy, but we learn to accept mortality and strive to make all deaths good deaths if at all possible.
10. Understand that the retrospectoscope trumps everything. When something bad happens to patients, we always obsess over our actions and decision making. We must learn to own our mistakes and learn from them.

Throughout our careers we always fret about possible mistakes. We often overestimate our potential for having been able to prevent bad outcomes.

We must share our experiences with our colleagues and as colleagues we must be supportive. We must learn from our mistakes and our colleagues mistakes. And we all make mistakes.

The session was informative and therapeutic. The students recommend that we do this again. They really appreciated learning that they were not the only ones who had these feelings, doubts and mental exercises.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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